Provider Demographics
NPI:1457613655
Name:GARDNER, SCOTT DONALD (MD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:DONALD
Last Name:GARDNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 BRANDYWINE BLVD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-1562
Mailing Address - Country:US
Mailing Address - Phone:770-719-7950
Mailing Address - Fax:770-460-1739
Practice Address - Street 1:340 BRANDYWINE BLVD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-1562
Practice Address - Country:US
Practice Address - Phone:770-719-7950
Practice Address - Fax:770-460-1739
Is Sole Proprietor?:No
Enumeration Date:2012-06-13
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA075189207W00000X, 207W00000X
SC34832208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I183334OtherMEDICARE PTAN
GA003175035AMedicaid